3 Mass. ERs cited for denial of care

Changes made; one patient died

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Health officials cited three Massachusetts hospitals in the past six months for wrongly sending away patients from their emergency rooms, in one case resulting in the death of a patient while en route to another facility.

In that episode, caregivers at Charlton Memorial Hospital in Fall River failed to provide needed medical treatment before transferring the patient, who was unstable and in respiratory distress, state investigators concluded.

In a case at St. Vincent Hospital in Worcester, an on-call surgeon refused to come in late at night to perform an emergency operation on a patient with flesh-eating bacteria, investigators found. The patient was transferred to another hospital, and the surgeon no longer operates on patients at St. Vincent, hospital officials said.

Hospitals that break federal rules ensuring public access to emergency services can face especially tough sanctions. Flagrant or repeat violators risk losing their right to treat Medicare and Medicaid patients, which can cost a hospital millions of dollars.

Charlton, St. Vincent, and Lahey Clinic in Burlington - which turned away an emergency room patient in November - have been told they will not lose their Medicare contracts, but they could be fined. Federal officials said it is unusual to have three cases in such a short span.

“It’s the very basic tenet of what we’re all about in health care,’’ said Dr. Mary Anna Sullivan, chief quality and safety officer at Lahey. “You take care of the patient who presents in the ED. End of story.’’

The Globe obtained copies of the state investigative reports through a Freedom of Information request. The reports contain details of the cases but do not identify the patients or the caregivers. In all three cases, Richard Shaw, the Boston branch chief of the Centers for Medicare & Medicaid Services, wrote letters to the hospitals saying he would not terminate their Medicare provider agreements because they “implemented corrective action that has been effective over the longer term.’’ He said that he referred the cases to the Office of the Inspector General for possible fines. A spokesman for the office said he could not comment.

Even though emergency rooms are growing more congested with patients, investigators said they did not find evidence that crowding was a factor in the three cases, which they do not believe are connected. But they said they are on alert for underlying pressures that might be contributing to patient care problems.

“We are watching it very closely,’’ said Dr. Madeleine Biondolillo, director of the state’s Bureau of Health Care Safety and Quality, in an interview.

The law guaranteeing access to emergency care originally was intended to prevent hospitals from turning away uninsured patients who cannot pay for treatment. The law requires hospitals to provide patients with a “medical screening exam’’ and to treat and stabilize patients with emergency medical conditions. Medicare officials said that there were 11 violations of the rules in New England last year, 13 in 2010, and seven in 2009.

Executives at Lahey and St. Vincent said lack of insurance was not a factor in the cases at their hospitals. Executives at Charlton, part of Southcoast Hospitals Group, would not answer questions about the case in which the patient died.

The Charlton patient was coughing and short of breath upon arriving in the emergency room at 7:30 p.m. Aug. 9. Over the next few hours, the patient, who had been diagnosed with a serious lung disease as a child, required oxygen. The patient had received care at a teaching hospital in the past and wanted to be transferred there. At 9:45 p.m., an emergency room doctor decided the patient was stable enough for a trip to the other hospital.

After another doctor came on duty about 10:30 p.m., the patient deteriorated. In citing the hospital in February, health officials said the second doctor failed to recognize that the patient was unstable and perhaps too sick to be moved - even though the ambulance crew expressed concerns - and that caregivers did not insert a breathing tube in case mechanical ventilation was needed on the ride.

“We continually strive to improve the access, quality, and effectiveness of our services and are dedicated to delivering the safest, highest quality care to all of our patients,’’ Charlton spokeswoman Stephanie Lynn Poyant said in a written statement. “We investigated the case carefully and made corrective actions that when surveyed by the Department of Public Health were found to have been effective over the longer term.’’

According to state documents, Charlton mandated that doctors and nurses reassess all patients before transfer, and that they exchange more information about patients during shift changes.

In the St. Vincent case, a patient arrived in the emergency room on Oct. 16 shortly before 8:30 p.m. with a fever and pain from an abscess on the right buttock. The physician who evaluated the patient told investigators the patient “was in poor shape’’ and needed emergency surgery in order to remove the dead tissue and improve chances of survival.

But state investigators said the hospital failed to ensure a surgeon was available. The surgeon on call would not come in that night and had “various reasons’’ for wanting to wait until 6 a.m., according to the state report dated Jan. 4. The surgeon told investigators “it was better for him to come to the hospital in the morning.’’

The emergency room doctor transferred the patient to UMass Memorial Medical Center, a competitor, because he did not want the patient to lose more time waiting for surgery. A UMass spokesman said he could not disclose the fate of the patient because of privacy rules.

Dr. Octavio Diaz, St. Vincent chief medical officer, said the surgeon, who was employed by a nearby medical group, “is no longer on the call schedule and no longer seeing patients here.’’

“It’s completely unacceptable to us,’’ he said. “The minutes do count. Antibiotics can slow this infection, but it’s an operation the patient needs. The ER did a terrific job recognizing this.’’

In the Lahey case, caregivers told a patient who arrived at the hospital in Peabody on Nov. 19 that he was banned from the emergency room there and from the hospital’s emergency room in Burlington. He was not evaluated or treated, and was “escorted off the grounds in a wheelchair by a security guard,’’ according to state investigators.

Sullivan, Lahey’s chief quality officer, citing privacy rules, would not say why caregivers attempted to ban the patient. She said he went to another hospital, which called Lahey several hours later and questioned why he wasn’t treated there. Lahey staff apologized and an ambulance brought him to the Burlington hospital, where he was admitted.

A nurse and a doctor involved in the case were put on unpaid leave for 30 days and retrained in the emergency care law, and all emergency room doctors and nurses will undergo yearly education on the regulations.

“This is a message to all of us that there are certain things we have to do and we have to get them right,’’ she said.